Adherence to Allergen Subcutaneous Immunotherapy is Increased by a Shortened Build-Up Phase: A Retrospective Study

Knowledge, Attitudes, and Practices of Patients with Allergic Rhinitis Towards Allergen-Specific Immunotherapy

Purpose

This study aimed to investigate the knowledge, attitudes, and practices (KAP) of patients with allergic rhinitis towards allergen-specific immunotherapy (AIT).

Methods

This cross-sectional study was conducted through a questionnaire survey at The Fourth Affiliated Hospital of Zhejiang University School of Medicine from October 15, 2023, to December 3, 2023.

Results

A total of 550 valid questionnaires were included in the analysis. The median scores with interquartile ranges (IQR) for knowledge, attitude, and practice were 17 (11, 23), (possible range: 0-34); 20 (17, 22), (possible range: 7-35); and 30 (24, 34), (possible range: 8-40). Multivariate logistic regression analysis showed that individuals engaging in physical activity 1-3 times per week (OR = 2.895, 95% CI: [1.745, 4.804], P < 0.001), those participating in physical activity 5-7 times per week (OR = 3.811, 95% CI: [1.502, 9.671], P = 0.005), and those with higher knowledge scores (OR = 4.485, 95% CI: [2.942, 6.837], P < 0.001) were independently associated with positive practices. The structural equation modeling (SEM) results revealed that knowledge had a significant influence on attitude (β = -0.354, P = 0.010) and practice (β = 0.618, P = 0.010), and attitude also demonstrated a noteworthy impact on practice (β = -0.120, P = 0.020). Furthermore, it is worth noting that the indirect effects of knowledge on practice were statistically significant (β = 0.042, P = 0.020).

Conclusion

Patients with allergic rhinitis had inadequate knowledge, negative attitudes and proactive practices towards AIT. To improve their understanding and adherence, healthcare providers should prioritize education and interventions aimed at enhancing patient engagement with this treatment option.

Long-term adherence strategies for allergen immunotherapy

Adherence is crucial for allergen immunotherapy (AIT) efficacy, and a long-term 3-year adherence is indispensable for the long-term benefits beyond AIT administration. Nonadherence causes should be analyzed not only at the patient level but from a broader perspective, including socioeconomic factors, health-care system factors, and disorder- and therapy-related factors. Subcutaneous immunotherapy (SCIT) adherence is ∼50% at best and, for sublingual immunotherapy, the numbers are even much worse in some regions. In this review, causes for AIT loss of adherence and strategies, published and from personal experience, to reduce nonadherence are presented. Although the broader picture of causes of nonadherence has to be taken into account, in all this, the patient-physician and patient-health care professional (AIT nurse, assistant) are still in the center, and, in SCIT, each clinic visit for a shot is an opportunity to exploit this interaction in a positive way and stimulate adherence. Patient factors of nonadherence are not so much forgetfulness but more perception of ineffectiveness and adverse effects. An explanation of what can be expected before starting AIT is crucial because most of those who drop out are seen during the first year. Adherence is especially under risk when administration is temporarily interrupted (lockdown, illness, disease flare, vacation, preseasonal AIT administration schedules). The pandemic has caused higher rates of nonadherence specifically due to a fear of getting infected with severe acute respiratory syndrome coronavirus 2, which can be mitigated with good hygiene techniques and strict sanitization protocols, which ensure the patients. Also, patient mobile discussion networks related to AIT can help encourage adherence and reduce fear of infection, even in these difficult times.

Preference for sublingual immunotherapy with tablets in a Spanish population with allergic rhinitis

BACKGROUND

This study investigated patients' preference for allergy immunotherapy (AIT) administered as either sublingual immunotherapy-tablets versus monthly or weekly subcutaneous immunotherapy (SCIT) from a Spanish patient perspective.

METHODS

A discrete choice experiment (DCE) consisting of two blocks with eight choice sets in each was constructed to elicit the preferences for AIT. Three attributes were included in the DCE for the mode of administration, including the frequency of administration, the risk of systemic reactions and the co-payment. Adults and caregivers of children with moderate to severe allergic rhinitis (AR) were included if they were not currently receiving or had not previously received AIT.

RESULTS

In total, 587 adults and 613 caregivers started the survey. Of those, 579 adults and 611 caregivers completed the survey and were included in the study. Both adults and caregivers had a significant preference for tablets compared with both monthly and weekly injections (p ≤ 0.0001). Furthermore, the respondents showed a significant preference for reducing the risk of systemic reactions. Subgroup analyses showed that caregivers of polyallergic children and female caregivers were significantly less price sensitive when choosing their preferred treatment.

CONCLUSION

Our study demonstrated that both adults with AR and caregivers of children with AR prefer daily SLIT-tablets to SCIT with either a weekly or monthly dose schedule.

Real-life studies in allergen immunotherapy

PURPOSE OF REVIEW

Real-life (or real-world) studies can provide information that cannot be derived from randomized controlled trials. This approach is currently becoming of relevance for many treatments. In recent years, the real-life method has been applied also to allergen immunotherapy, providing new insights on it. We reviewed herein the available literature on the argument.

RECENT FINDINGS

Several prospective and retrospective studies on allergen immunotherapy in the real-world setting have been published, mostly in the last 5 years. Most of them focused on adverse events, compliance, and the long term/preventive effects, and evidenced an overall favorable profile for different products and different allergens.

SUMMARY

Real life study provided novel information and evidenced those aspects of immunotherapy that worth a more detailed approach, without the strict limitations usually imposed by controlled randomized trials.

Real-life adherence to subcutaneous immunotherapy: What has changed in the era of the COVID-19 pandemic

BACKGROUND

Allergen immunotherapy (AIT) must be continued for 3 years, to achieve a long-term modifying effect. Adherence is a key to ensure effectiveness. The objective of this study was, first of all, to evaluate the adherence with subcutaneous immunotherapy (SCIT) and to identify the main causes of SCIT withdrawal in real-life practice in our clinic. Secondly, we also aimed to investigate to what extent the COVID-19 pandemic altered our SCIT receiving patients' treatment adherence behaviors and the factors that affected their decisions.

METHODS

Retrospective analysis of the medical records of patients ages ≥18 years, who had started SCIT in January 2014 or later until September 2020 in our department for the diagnosis of allergic rhinitis, allergic asthma or venom allergy, were included in the study. Adherence was determined as the accomplishment of 3 years of SCIT.

RESULTS

A total of 124 patients (72 female [58.1%]; median age, 35 [19-77] years) were included. The adherence rate to SCIT in our tertiary center's real-life setting was 56.25% with a follow-up duration of 3 years before COVID-19 pandemic. Dose modification, defined as reducing patient's planned SCIT dose due to a systemic allergic/large local reaction or missed injection, and its frequency, which is the number of dose adjustments done throughout the SCIT, was found to be the only factor related to nonadherence. But with the pandemic only in 6 months, among 63 patients receiving SCIT, 15 patients (23.81%) dropped out, and the most common reason was fear of being infected with COVID-19 virus during receiving SCIT in hospital (93.33%). The only independent predictor of drop-out during the COVID-19 pandemic was short duration of AIT (p = 0.012). When we compare the dropped-out cases before and after the start of pandemic, AIT duration was significantly shorter in pandemic period (p = 0.005).

CONCLUSION

Adherence rate to SCIT in our real-world setting study was 56.25% before the COVID-19 pandemic. Our results indicated that patients requiring dose modification were more prone to be non-adherent. Approximately one quarter of patients dropped-out with the start of pandemic, almost all due to fear of being infected during receiving SCIT in hospital. Since short SCIT follow-up time was found to be the only risk factor for drop-out during the COVID-19 pandemic, we believe that patients who are in the early phases of their treatment should be observed more closely and their concerns should be answered by their doctors.

Allergens and Adjuvants in Allergen Immunotherapy for Immune Activation, Tolerance, and Resilience

Allergen immunotherapy (AIT) is the only setting in which a vaccine is applied in patients allergic exactly to the active principle in the vaccine. Therefore, AIT products need to be not only effective but also safe. In Europe, for subcutaneous AIT, this has been achieved by the allergoid strategy in which IgE epitopes are destroyed or masked. In addition, adjuvants physically precipitate the allergen at the injection site to prevent too rapid systemic distribution. The choice of adjuvant critically shapes the efficacy and type of immune response to the injected allergen. In contrast to T_H2-promoting adjuvants, others clearly counteract allergy. Marketed products in Europe are formulated with aluminum hydroxide (alum) (66.7%), microcrystalline tyrosine (16.7%), calcium phosphate (11.1%), or the T_H1 adjuvant monophosphoryl lipid A (5.6%). In contrast to the European practice, in the United States mostly nonadjuvanted extracts and no allergoids are used for subcutaneous AIT, highlighting not only a regulatory but maybe a "historic preference." Sublingual AIT in the form of drops or tablets is currently applied worldwide without adjuvants, usually with higher safety but lower patient adherence than subcutaneous AIT. This article will discuss how AIT and adjuvants modulate the immune response in the treated patient toward immune activation, modulation, or-with new developments in the pipeline-immune resilience.